Provider Demographics
NPI:1447239264
Name:HOLZER, PHILLIP J (OD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:J
Last Name:HOLZER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 COSHOCTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050
Mailing Address - Country:US
Mailing Address - Phone:740-393-9000
Mailing Address - Fax:740-392-0167
Practice Address - Street 1:1330 COSHOCTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050
Practice Address - Country:US
Practice Address - Phone:740-393-9000
Practice Address - Fax:740-392-0167
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2764152W00000X
OHOPT006518152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38606500Medicaid
WI38606500Medicaid
WI0428 20195Medicare ID - Type Unspecified